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Reflections on battered women: gender violence and mental health. (Consequences of Gender Violence).

Introduction

Although gender-based violence is far from being a new phenomenon, recent events have played a decisive role in bringing it to light and shifting it from the private to the public realm. Of particular importance was the United Nations General Assembly's "Declaration on the Elimination of all Forms of Violence against Women," approved in December, 1993 (Res. A.G. 48/104), as well as the Fourth World Conference on Women held in Beijing in September, 1995. In a recent article we described in detail the visibilization of domestic violence (Bosch and Ferrer, 2000).

For the purposes of this article, we will use the definition of gender-based or sex-specific sexual violence published recently in the glossary of the European Commission (1999) as "any form of violence by the use or threat of physical or emotional force, including rape, wife battering, sexual harassment, incest and pedophilia."

The World Health Organization, at its 44th World Health Assembly held in May 1996, recognized in a resolution (WHA 49.25) the important increase in the incidence of intentionally-inflicted injuries which affect people of all ages and both sexes, but in particular women and children. The Assembly declared that violence against women is a public health priority because of its serious immediate and long-term consequences for individuals, families and communities. The following year WHO adopted a new resolution (WHA 50.19) insisting that violence against women is a social and sanitary problem of the highest magnitude that requires urgent action.

According to WHO (1998a), violence against women is a priority issue for health professionals for the following reasons:

Although its nature as a "hidden crime" makes the true dimensions of violence hard to ascertain (WHO, 1998b; n.d./1999), at least 20% of all women are estimated to suffer in some way as a result of violence. The available data provided in a number of regional reports from various organizations and institutes suggest that between 20% and 50% of all women have suffered violence from their partner at some time in their relationship and that 25% are now living or have lived in a violent situation (Eriksson, 1997; WHO, 1996, 1998a).

Despite its invisibility, more and more studies recognize the negative impact of violence against women on a wide range of important health issues, such as safe motherhood, family planning, mental health, chronic illnesses, etc. (WHO, 1998b; n.d./1999). For many women victims, health professionals are their most important source of support.

In this article we will look at the mental health repercussions of one type of gender-based violence--domestic violence.

For a working definition, we return to the glossary of the European Commission: Domestic violence or family violence is defined as "any form of physical, sexual or psychological violence which puts the safety or welfare of a family member at risk and/or the use of physical or emotional force or threat of physical force, including sexual violence, within the family or the household. Includes child abuse, incest, wife battering and sexual or other abuse of any member of the household." Of all these forms of domestic violence, this article will focus on what the European Commission terms wife battering and defines as "violence against women by their partner."

Repercussions of Violence Against Women

Recently, WHO (1998a, 1998b; n.d./ 1999) established the following categories of repercussions of violence against women:

A. Fatal outcomes: suicide, homicide, maternal mortality, AIDS.

B. Non-fatal outcomes:

a. To physical health: injuries; unwanted and/or early pregnancy; abortion or other injuries occurring during pregnancy; sexually transmitted diseases; gynecological problems; pelvic inflammatory disease; chronic pain (pelvic, headache, etc.); irritable bowl syndrome; alcohol or drug abuse; self-destructive behaviors (smoking, unprotected sex, etc.); permanent disability; asthma; and general vulnerability to diseases or severe health problems.

b. To mental health: depression; fear; anxiety; low self-esteem; sexual dysfunction; eating disorders; obsessive-compulsive disorder; multiple personality disorder; posttraumatic stress disorder.

A number of hypotheses have been formulated as to the possible routes by which violence may affect health (Koss, Koss and Woodruff, 1991), including: 1. Reduced natural resistance or immunity caused by violence-related stress; 2. Changes in health habits in response to the trauma, including lack of attention to one's own health and assumption of greater risks; 3. Undocumented secondary physical damages caused by violence; 4. Chronic over-stimulation due to post-traumatic stress disorder; 5. Focalization of internal sensations; 6. Erroneous interpretation of symptoms, including normal psychological sensations accompanying emotional distress; and 7. Interaction with a biomedically-oriented health care system.

Resnick, Acierno and Kilpatrick (1997) propose a model which suggests different potential mechanisms through which the violent episode could augment the risk of health problems (see Figure 1).

[FIGURE 1 OMITTED]

Although this model includes both physical as well as mental health problems, in this article we will examine only issues related to mental health. Elsewhere, we have reviewed the available data on the repercussions of abuse on the physical health of women (Ferrer and Bosch, 2000).

The Link Between Domestic Violence and Mental Health

As the literature on the subject indicates, the psycho-pathological disturbances most frequently associated with abuse are depression and posttraumatic stress disorder.

Other relatively frequent mental disturbances in women victims of domestic violence are: anxiety-related disorders, such as panic attacks or obsessive-compulsive disorder (Jaffe et al., 1986; Follingstad et al., 1991; Goodman, Koss and Russo, 1993; Zubizarreta et al., 1994; Roberts et al., 1998); brief reactive disturbances, dissociative states or psychoses (Roberts et al., 1998); eating disorders, such as anorexia and bulimia (Walker, 1984); and alcoholism and drug dependencies (Roberts et al., 1998).

The available data suggest that women who suffer from abuse are between four and six times more likely to need psychiatric treatment than other women (WHO, 1998a).

Recently, the Women's Institute of Spain's Ministry of Labor and Social Affairs surveyed a broad sample of women and found that abused women most often manifested the following symptoms:

These data coincide with the impressions gathered from the scientific literature on the subject.

Given that depression and posttraumatic stress disorder are the most frequently cited psycho-pathological disturbances in these women, we will concentrate on these two problems.

Depression

The high rate of depression among victims of abuse is similar to that found in other victims of traumatic events. Diverse studies in this respect (Walker, 1984; Jaffe et al., 1986; Sato and Heiby, 1991, 1992; Cascardi and O'Leary, 1992; Goodman, Koss and Russo, 1993; Zubizarreta et al., 1994; Campbell, Sullivan and Davidson, 1995; Echeburua et al., 1997; Roberts et al., 1998) indicate that between 47% and 80% of abuse victims suffer from depression.

Some characteristics of wife battering are directly linked to the appearance of depressive disturbances (Staats and Heiby, 1985). For example, the abuser punishes the victim when she shows adaptive responses (expressing fear, anger, looking for help). Any attempt by the victim to defend herself may increase the intensity of the abuse. As a result, a battered woman will be less likely to recur to these adaptive responses in the future. When the victim tries to end the relationship, the risk of further abuse and even murder increases. Abuse is even more damaging when it is inconsistent or accompanied by sporadic reinforcements, that is, when a particular conduct is punished on some occasions and not on others.

On the other hand, the abuser often prevents the victim from recurring to her habitual sources of reinforcement. isolating her from her friends, her hobbies, even her work. This social isolation favors the dependence on the aggressor and converts him into the only source of social and material comfort.

In addition, by reinforcing certain nonadaptive behaviors, the depression is deepened and maintained. Battered women receive positive reinforcement from their partners for remaining submissive, passive and dependent--all characteristics of depression. Continuous abuse can have serious effects on self-esteem, increasing the vulnerability to depression

Post-traumatic stress disorder

It has been suggested recently that a diagnosis of post-traumatic stress syndrome provides an appropriate description of the psychological consequences of domestic violence on women.

The American Psychiatric Association introduced this disorder as a diagnostic category in the third edition of its Diagnostic and Statistical Manual of Mental Illnesses (DSM-III; APA, 1985), with the aim of combining a set of diagnoses which previously had been considered separately (rape trauma syndrome, war neurosis, survivor's syndrome, etc.) The new term encompasses a set of anxiety symptoms which manifest themselves in a similar way in most individuals who confront a psychologically traumatic event outside the usual framework of human experience. This diagnosis is applicable to situations such as natural disasters and accidents.

In the most recent edition of this manual (DSM-IV, 1995), emphasis is shifted toward the reaction of the individual and away from the type of traumatic event. The criteria proposed for this diagnosis include: exposure to a traumatic event; reliving the event through recurrent thoughts or dreams; persistent avoidance of stimuli associated with the trauma; dulling or numbing associated with regular life activities; persistent activation symptoms; and the prolonging of these alterations (which provoke significant discomfort or dysfunction) for longer than one month. This modification permits the inclusion in this clinical diagnosis not only of victims of extraordinary or freak events but also of other types of victims, such as abused women (Echeburua and Corral, 1996).

The few studies of symptoms of posttraumatic stress in victims of abuse tend to suggest that an important percentage (between 45% and 55%) fulfill the criteria required to confirm a diagnosis (Walker, 1989; Houskamp and Foy, 1991; Dutton, 1992; Goodman, Koss and Russo, 1993; Villavicencio, Sebastian and Ruiz, 1994; Zubizarreta et al., 1994; Echeburua et al., 1996, 1997).

Certain circumstances related to the abuse are predictors of the appearance of post-traumatic stress disorder (Echeburua and Corral, 1996). Among these factors are: prolonged duration of the traumatic situation; situations which threaten life or serious injury to the victim; low level of social support; and economic problems. Another aggravating factor is the occurrence of the traumatic experience in an area supposedly "safe" for the victim, such as her house or place of work.

In addition, as DSM-IV (1995) suggests, this disturbance can become especially serious or long-lasting when the stress-provoking agent is another human being. The probability of post-traumatic stress disorder increases in accordance with the level of intensity or physical proximity of the source of stress. When the cause of the trauma is another person, the following symptoms can appear: emotional imbalance; impulsive and self-destructive behavior; dissociative symptoms; sleep disorders; feelings of uselessness, shame, desperation or despair; sensation of constant danger or vulnerability; loss of previous beliefs; hostility; social withdrawal; deterioration of interpersonal relations; and changes in personality.

All these aggravating circumstances--prolonged aggression over time; life-threatening situations; abuse occurring within a supposedly safe area; physical proximity of the aggressor--are present among victims of domestic violence. In addition, the abuser is (or was) someone that they loved or respected. The batterer is the person with whom they have chosen to share their life, with whom they share lifelong goals and plans. It is precisely the level of emotional proximity that aggravates the intensity of the experience (Goodman, et al., 1993).

Finally, it is important to remember that not all victims of traumatic situations suffer from this disorder. The psychological reaction to an experience depends on the intensity of the trauma, the circumstances surrounding the event, the victim's age, history of previous abuses, previous emotional stability, psychological resources, self-esteem, social and family support, and current emotional relationships (Echeburua and Corral, 1996).

Some Conclusions

Victims of domestic violence suffer physical and mental health consequences, the latter concentrated in depression and post-traumatic stress disorder. Understanding the consequence of violence for the women also can indicate the most appropriate types of interventions in these cases.

Nevertheless, beyond the undoubted usefulness of these findings, Villavicencio and colleagues, among others (Villavicencio and Batista, 1992; Villavicencio and Sebastian, 1999; Roberts et al., 1998), note that these mental health problems are usually the consequence of the abuse itself. However, the cause is not always explicitly identified in the diagnosis, post-traumatic stress disorder being the most obvious exception.

In the case of battered women, an emotionally-supportive social environment, based on the recognition of abuse as a crucial social problem, constitutes an important factor in an eventual psychological recovery.

Goodman et al. recall (1993) that because battered women are not a uniform group, the consequences of abuse vary. Some suggest that the variety and severity of the symptoms and consequences of abuse on a woman's mental health will be related to the frequency of the abuse, the presence of emotional abuse, adjustment to the traditional gender role, the perception of the violence as more or less lethal, family history of abuse, etc. (Follingstad, et al., 1991; Goodman et al., 1993). All these factors must be taken into account.
Table 1. Symptoms of Women Victims of Abuse

Symptom Abused Women (%) All Women (%)

Headaches 51.8 43.3
Pain in back or joints 72.1 64.2
Flu 27.3 21.8
Chronic fatigue 27.6 16.8
Insomnia 47.2 34.9
Mood swings 72.4 53.1
Desire to cry for no reason 50.3 31.7
Sadness 40.6 21.3
Anxiety or anguish 52.3 32.0
Irritability 54.2 35.1
Lack of libido 44.0 23.6

Source: Survey from the Instituto de la Mujer
(Women's Institute) as reported in El Pais,
March 9, 2000 (Iribar, 2000b).


The authors are psychologists and faculty members of the Psychology Department of the Universitat de les Illes Balears, Palma de Mallorca, Balearic Islands, Spain.

References

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Author:Fiol, Esperanca Bosch
Publication:Women's Health Collection
Geographic Code:4EUSP
Date:Jan 1, 2001
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